Screening for Addiction in Primary Care Settings

Alcohol, nicotine, and other drug use are common behaviors: two thirds of American adults drink alcohol, and one quarter of adults smoke tobacco. Problems from use are also common, and diagnosable substance use disorders are highly prevalent, over 12% of adults exhibiting addiction to alcohol or another drug (exclusive of nicotine), and almost 24% of adults being regular nicotine users (most of these being addicted to the nicotine).

Given that alcoholism and other drug dependencies are progressive conditions, early detection and early intervention can be effective strategies in diminishing the duration, and thus the prevalence, of these conditions in the population. Furthermore, early intervention can diminish the pattern of problems resultant from substance use.

It is estimated that over two-thirds of persons with addiction see a primary care or urgent care physician every six months. Thus, physicians have an opportunity to recognize, diagnose, and intervene in cases of substance use problems and substance-related disorders. Proper training in detection and intervention techniques, and proper motivation on the part of physicians to utilize these techniques, are necessary for these techniques to be widely employed. Screening techniques comprise one process by which physicians and other primary health care providers can determine whether or not to intervene in the course of a substance-related disorder and whether and when to apply more specific diagnostic or therapeutic procedures on behalf of the patient.

A review of available literature by ASAM leads to the conclusion that screening for alcohol and other drug problems is a clinical process that is effective in enhancing health care outcomes, a cost-effective process that reduces overall healthcare expenditures, a preventive health care intervention that is of equivalent importance to other screening interventions, such as screening for breast or cervical cancer, and an activity that should be promoted so that it will become part of the public consciousness of health care consumers, providers, purchasers, administrators, quality managers, and public policy makers.

The quality and efficacy of routine health care services for any condition are compromised unless the patient's alcohol and other drug usage pattern and history are known to the clinician planning and providing primary health care interventions.

Therefore, ASAM recommends:

1. That the services of primary care physicians and other primary health care providers should at a minimum include the provision of the following four elements of care:

• assessment of the nature and extent of alcohol, nicotine, and other drug use by patients, with consistency of data collection and documentation akin to the consistence of assessment and documentation of vital signs;
• routine screening for the presence of alcohol, nicotine or other drug use problems in patients, as well as screening for risk factors for development of alcohol, nicotine and other drug dependence;
• appropriate intervention by the primary care provider;
• the provision of ongoing general medical care services to persons who manifest alcohol, nicotine or other drug problems, including dependence.

2. That health care services to prevent, screen for, assess, and intervene regarding alcohol, nicotine and other drug problems should be considered to be a component of general medical practice.

3. That screening for alcohol, nicotine and other drug use problems is of special importance in clinical situations (such as trauma patients, obstetrical patients and adolescent psychiatry patients), where substance use is particularly relevant to assessment and management.

5. That benefits packages for health care services should address addictive diseases, including the diagnosable syndromes of substance use and dependence, equivalent to the way other chronic conditions are addressed.

6. That the interrelatedness of the biomedical and emotional-behavioral aspects of many chronic diseases, including alcohol, nicotine and other drug dependence, suggests that an integrated approach to assessment and intervention will be preferable to any approach that separates health care services, delivery system structures, and reimbursement policies and benefit structures for alcohol, nicotine, other drug, or mental disorders, from such services, structures, and policies for other health care conditions.

7. That health care organizations which provide, contract for, arrange, or purchase medical care should assure that screening processes are designed and implemented effectively and routinely in primary care settings, in order to ascertain the presence of alcohol, nicotine and other drug problems, including dependence.

8. That purchasers of health care services should make it a specification of services provided, as well as a measure of the quality of services provided, that screening for alcohol, nicotine and other drug problems by primary care providers be a routine clinical function.

9. That contract language between purchasers (employers or governmental entities) and organized systems of health care delivery should follow a model which includes appropriate screening for chronic conditions, including alcohol, nicotine and other drug dependence, and which also includes data collection regarding health care outcomes and health care expenditures for patients/enrollees identified as having alcohol, nicotine or other drug dependence.

10. That the JCAHO, the NCQA, and other organizations which accredit, monitor and evaluate the performance of healthcare organizations should recognize that screening for alcohol, nicotine and other drug disorders is a fundamental function of primary health care service, and therefore should include such screening as a standard by which quality performance is measured.

11. That screening for alcohol, nicotine and other drug problems be included by the developers of HEDIS and other quality assurance and quality improvement standards as a "report card" item for evaluating the quality of services provided by an organized system of health care delivery.

12. That as states request waivers which may allow them to change the structure, processes, benefit structures, eligibilities, and policies of their Medicaid programs, the new structures, processes, etc., will include requirements for

• screening of all patients in primary health care settings for alcohol, nicotine and other drug use problems;
• appropriate care for persons with alcohol, nicotine and other drug use disorders, in either primary care or specialized care settings.

13. That clinical practice guidelines should be developed and utilized which describe appropriate integration of screening, assessment, and intervention for alcohol, nicotine and other drug problems into routine primary medical care processes.

14. That health care organizations should be encouraged to assure that the assessment of potential alcohol, nicotine and other drug use problems should, when feasible, involve the patient's family members and other collateral sources of information.

15. That individuals served by organized systems of health care should be screened to determine the impact upon them of the alcohol, nicotine and other drug use problems of their family members.

16. That organized systems of health care delivery, such as health maintenance organizations, should be encouraged to assure that primary care providers will provide, or refer for, appropriate counseling and referral services for family members affected by an alcohol or other drug use problem in the family.

17. That implementation of screening procedures for substance use and/or addictive illness should preserve the special needs for confidentiality of patients with substance use conditions.